TRAUMATIC INJURIES OF THE STOMACH
Abdominal trauma can cause serious injury to the stomach, small bowel, and colon. The nature and severity of the injury depend upon whether the injury mechanism is blunt or penetrating.
Blunt gastrointestinal injury may result in crushing of the bowel between the body’s solid structures, such as the spine or pelvis, and an external blunt force, such as a steering wheel, seatbelt, or handlebar. Blunt gastrointestinal injury occurs more commonly in the small bowel, followed by the colon and then the stomach. Rupture of the stomach is relatively uncommon because of the stomach’s relatively protected anatomic location.
Injuries of the stomach occur relatively frequently with any penetrating or perforating wound of the abdomen, as can occur with gunshots and knife stabbings. According to statistical data of war surgery, about 8% of abdominal wounds involve the stomach, and in approximately 5% the stomach alone is injured. With blunt trauma to the upper abdominal region, the stomach may become lacerated, or it may even rupture if the organ is filled and distended at the moment of impact.
The type of gastric wound produced by a bullet or sharp instrument depends upon the size, shape, course, and velocity of the wounding agent. Bullets that enter from the front, taking an anteroposterior course, often cause only small perforations of the wall. Larger shell fragments can produce rather extensive jagged lacerations, which may completely sever the stomach from the duodenum, particularly if they include the gastric antrum. Wounds of the cardia often involve the lower end of the esophagus and mediastinum.
The clinical manifestations of any perforating injury of the stomach are often very dramatic. Depending upon the size of the wound, the loss of blood, and the presence or absence of concomitant injuries, either shock or signs of peritonitis dominate the clinical picture. Small perforations, causing little shock, may first cause localized and then diffuse pain, which is soon followed by rigidity of the abdominal wall, nausea, and vomiting of bloody material. The entry of air into the abdominal cavity can be demonstrated radiologically. Small perforating injuries of the cardia produce, in the beginning, very few or no clinical symptoms. In most cases only left shoulder pain due to an inflammatory reaction of the diaphragmatic peritoneum is present.
The prognosis of any gastric wound depends upon the promptness of appropriate treatment, which is primarily surgical intervention, rather than upon the type and degree of the injury. In World War I, the mortality rate for all gastric wounds ranged between 50% and 60%, owing to the frequency of hemorrhagic shock and peritoneal infection, and the rate for uncomplicated wounds restricted to the stomach ranged between 25% and 50%. Much progress has been made since then in treating shock and infection, including improved access to medical care with trauma centers, resulting in a tremendous reduction in these mortality figures.
Treatment for injuries of the stomach is primarily surgical, done at the earliest possible time. With both gunshot and stab wounds, the posterior as well as the anterior wall may be injured simultaneously, so that it becomes obligatory to explore the posterior wall in every instance by adequately detaching the gastrocolic ligament and pulling the stomach upward. Cases in which the anterior gastric wall has remained intact and the posterior wall alone has been perforated, even though the shot or puncturing instrument entered through the anterior abdominal wall, have been reported. This can happen if, at the time of the accident, the stomach was so tightly filled that the greater curvature, rotating around the longitudinal axis of the stomach, has turned forward and upward. In this position the inferior aspect of the posterior wall approaches the anterior abdominal wall.
Extensive destructive wounds, with major defects of the stomach, cannot be repaired and make a typical gastrectomy or removal of large parts of the stomach inevitable.
If the cardia has been injured, a left thoracotomy becomes necessary in order to ensure a sufficient view and also freedom of action to perform a gastroesophageal resection in instances in which the esophagus also is found to be involved.